R1 VA Plastics
TABLE OF CONTENTS ............................................................. ------------------------------------------------------------------------------- To find a section of the guide use Ctrl +F to jump to the section of interest 0.0.0 Introduction 1.0.0 Typical Days 1.1.0 Monday 1.1.1 Main OR 1.2.0 Tuesday 1.2.1 Main OR 1.2.2 Gyn OR 1.2.3 Evening Conferences 1.3.0 Wednesday 1.3.1 Morning Conference 1.3.2 Pre-Operative Conference 1.3.3 Afternoon Clinic 1.4.0 Thursday 1.4.1 Procedure Room OR 1.4.2 Afternoon Clinic (Sepulveda) 1.5.0 Friday 1.5.1 Morning Clinic 1.6.0 Weekends 1.6.1 Call Days 1.6.2 Non-Call Days 2.0.0 Call Schedule 2.1.0 Weekday Call 2.2.0 Weekend Call 3.0.0 Operating Room 3.1.0 Main OR 3.1.1 Night Before 3.2.0 Procedure Room OR 3.2.1 Night Before 3.2.2 Day of Surgery 3.3.0 Orders/Notes 3.3.1 Outpatient Surgery 3.3.2 Inpatient Surgery 3.4.0 General Information 3.4.1 Consents 3.4.2 Marking 4.0.0 Clinic 4.1.0 Times/Locations 4.1.1 WLA Clinic 4.1.2 Sepulveda Clinic 4.2.0 Responsibilities 4.2.1 See Patients 4.2.2 Write Notes 4.2.3 Get Consents 4.2.4 Procedures 4.2.5 RTC Orders 5.0.0 Rounding 5.1.0 Weekdays 5.1.1 Primary Patients 5.1.2 Consult Patients 5.2.0 Weekends 6.0.0 New Consults 6.1.0 Inpatient 6.2.0 ER 6.3.0 Clinic 7.0.0 Ob/Gyn 7.1.0 Overview 7.2.0 Post-Op Orders 7.3.0 Inpatients 7.4.0 Signout 8.0.0 Writing Notes 8.1.0 Types of Notes 8.2.0 Attending Supervision 8.3.0 Cosigners 8.4.0 Encounter Information 8.4.1 Visit Type (very important) 8.4.2 Diagnosis (less important) 8.4.3 Procedures (very important, but only applicable for clinic/procedureRoom procedures) 9.0.0 Signout 10.0.0 FAQ �0.0.0 Introduction This is meant to supplement the VA Plastics intern signout. This is not a definitive guide – definitely feel free to update/clarify/correct/augment as needed. 1.0.0 Typical Days 1.1.0 Monday 1.1.1 Main OR All day OR cases with Dr. Rudkin or Festekjian (or occasionally Lee or Roostaeian) See “Main OR” in 3.1.0.0 1.2.0 Tuesday 1.2.1 Main OR All day OR cases with Dr. Rudkin or Festekjian (or occasionally Lee or Roostaeian) See “Main OR” in 3.1.0 1.2.2 Gyn OR Tuesday is GYN’s OR day and they will have 2-4 cases going in one room. You don’t have to do anything pre/intra-op, but will be paged for post-op orders as soon as each patient gets to the PACU. For non-admits, the Gyn fellow will generally just write the d/c orders/notes himself, but you may get paged by nurses if there are problems with a patient’s orders. For patient’s being admitted the GYN Fellow will text you with whatever admission orders he wants you to write. See 7.3.0.0 for a typical order set You won’t necessarily know when these pages/txts will come, so best to leave your pager+cell on the nursing stand while you scrub. It is expected that time-sensitive post-op GYN orders take priority over anything non-urgent in the OR 1.2.3 Evening Conferences Journal Club and Grand Rounds each occur once a month on Tuesday evenings at 5:30pm. Ask your fellow about their location and whether you are expected to attend (required for integrated residents) 1.3.0 Wednesday 1.3.1 Morning Conference - Integrated residents go to 7a Plastics Conference in Bld 200 (usually rm 206) - All other interns go to 7a Gen Surg Conf in CHPD - Signout your pager to the xcover intern during this time - You will typically *not* pre-round before conference on these days 1.3.2 Pre-Operative Conference 11a-12p in the 6W Surgery Conference rm. During this time the Plastics fellow will present next week’s OR cases to Drs Rudkin and Miller for planning/discussion. This is mostly for the fellow’s sake, and you don’t have to do anything in preparation for this, but since these will be the cases that you work on the following week it is definitely a good idea to pay attention and take notes. 1.3.3 Afternoon Clinic 12:30p-5p in the 1st flr Surgery Clinic. This is primarily Dr. Festekjian’s clinic, although Dr. Lee is frequently around to help see patients as well (especially her post-ops). See “Clinic” in 4.0.0 1.4.0 Thursday 1.4.1 Procedure Room OR - 8a-2p with Dr. Rudkin and Plastics fellow - Will typically work directly with fellow for “lumps & bumps” cases - See “Procedure Room OR” in 3.2.0 1.4.2 Afternoon Clinic (Sepulveda) - 1st and 3rd Thursdays of every month - 1p-5p at 16111 Plummer Street (3rd Flr, Plastic Surgery) with Dr. Lee - It’s a 30 min drive from WLA, so try to leave by 12:15p to arrive 15 min early (If no inpatients and no tasks left to do at WLA, make sure to print/leave a signout sheet for xcover so you have the option of going directly home from clinic if no reason to return to WLA campus afterward still need to call/text them at 6pm to touch base) 1.5.0 Friday 1.5.1 Morning Clinic - 8a-12p in the 1st flr Surgery Clinic with Dr. Rudkin - See “Clinic” in 4.0.0 1.6.0 Weekends 1.6.1 Call Days Saturday/Sunday Day Call: Arrive at 7am and grab the xCover pager from the 5-South workroom (it’ll be sitting under the whiteboard in the back room). You are responsible for all inpatient and consult pages until 7-8p, per the latest VA intern call documentation. The Plastics fellow/attendings will not come in to round with you, so you are responsible for rounding on all service patients yourself and writing notes. If any issues arise with these patients, txt the on-call plastics fellow. Individuals services will track you down throughout the day to give you their own signouts and fellow name/cell#s. End of shift signout is from 7p-8p in the 5-South workroom. Saturday Night Call: Same as above, but from 7p-7a. Since you will be in house anyway for parts of both Saturday and Sunday, it is generally polite to offer to round on any Plastics inpatients on both days (Sat before your shift starts, and anytime early Sun morning), so that the fellow doesn’t have to come in. In this case, write separate Saturday evening and Sunday morning notes, and text the fellow if there are any issues. 1.6.2 Non-Call Days These are typically days off. If there are inpatients, the fellow will generally come in and round on them so that you don’t have to. Make sure they know which day/days you are on call each weekend so they can prepare accordingly. They are not always the best about giving signout, so please (1) send the fellow’s name/cell# to the on-call day intern and (2) send the on-call day intern’s name/cell# to the fellow, so they both know who to contact if anything comes up. You can just do this during the day on Friday so you don’t have to worry about it over the weekend, but make sure fellow *actually communicates* w/ xcover each day. 2.0.0 Call Schedule You will typically be assigned to 1 weekday (2 hr) call and 3 weekend (12 hr) calls, as described below: 2.1.0 Weekday Call This is also called “short call” or sometimes “fake call”. Essentially, you will be covering any new consults for all surgery services that come in between 6pm and 8pm on a given weekday night. There is no formal call pager to pick up. The surgery fellow is typically still contacted first (either by the ER or Anesthesia night intern), and they will then contact you directly to assist them with the consult. Supposedly this system exists primarily to allow chiefs/fellows from busy services the cover required to sneak out of the hospital and get dinner. 2.2.0 Weekend Call See 1.6.1 above 3.0.0 Operating Room 3.1.0 Main OR These are general/MAC anesthesia cases in ORs 1-8 (usually 3 or 6) 3.1.1 Night Before - Briefly review all scheduled patients/cases - Check to make sure all patients have Consents. Double check that procedure name, anesthesia type, and attending providers are correct - Write/pend post-op orders and notes 3.1.2 Day Of Surgery - Arrive at pre-op (5-North) at 7:00 (1st case starts at 8a) - Ensure 1st patient is there in 5-N (name/bay# will listed be on white board) - If 1st patient not there, then go down to 4-East pod B (pre-pre-op) and see if patient is there (name/room# will be on white board). - If 1st patient is there, ask nurses to bring him up to 5-N - If 1st patient *not* there, ask nurses to call patient and inquire about delay; also txt fellow so he knows that 1st patient is delayed - If 1st patient is there, then figure out if plastics attending is there yet, and txt fellow accordingly (e.g., “1st patient up in 5N, Dr. Rudkin here too) - Wait for fellow to arrive; have marking pen ready, and assist as needed - Periodically check OR room to see if they are “ready” to do a timeout (this is done in OR before patient is taken back). Once they are ready, text the fellow - Use any down-time to modify/update your pre-writing orders/notes as you learn about any changes/clarifications to the procedure or dispo (most patients will go home the same day, except free flaps) - Once patient arrives in room, put on gloves and assist with shaving/prepping/etc - Scrub whenever the fellow scrubs - Assist with case (you will typically be 2nd assist for non-micro, 3rd assist for micro cases) - After case, accompany patient to PACU and let nurse know about any issues - Return to 5-North preop and repeat process for next case 3.2.0 Procedure Room OR These are local anesthesia cases in ORs 9-10 Note: - Patients fully awake during these cases - No scrub nurse and no anesthesia; just a circulator - Will have to transport patient yourself - Will have to pull your own sutures and dressings beforehand and drop onto sterile field - No gowning; just scrub and glove yourself 3.2.1 Night Before - Briefly review all scheduled patients/cases - Check to make sure all patients have Consents. Double check that procedure name, anesthesia type (***needs to be NONE***), and attending providers are correct - Write/pend post-op orders and notes (extra important, since these cases typically have minimal turnover time) 3.2.2 Day of Surgery I’d recommend dropping by 4-E Workroom around 645a for 5-10 min first thing in the morning to sign your narcotics orders for all patients, since you’ll need your VA Badge and many OR computers don’t have badge readers. You can also sign the patient discharge orders at this point, since everyone goes home that day. Just don’t sign the OpNotes or DispoInstructions until after each surgery is completed. - Arrive at pre-op (5-North) at 7:00 (1st case starts at 8a) - Ensure 1st patient is there in 5-N (name/bay# will listed be on white board) - If 1st patient not there, then go down to 4-East pod B (pre-pre-op) and see if patient is there (name/room# will be on white board). - If 1st patient is there, ask nurses to bring him up to 5-N - If 1st patient *not* there, ask nurses to call patient and inquire about delay; also txt fellow so he knows that 1st patient is delayed - If 1st patient is there, then text fellow accordingly - Wait for fellow to arrive; have marking pen ready, and assist as needed Unlike Main OR, no need to do pre-patient timeout, so can just wheel patient back to OR 9/10 once they are marked and consent verified. The access doors outside ORs 9/10 are locked and only nurses have keys. You can try buzzing on the intercom, but otherwise go back to pre-op and ask a nurse if they can let you in. - Once you’ve brought patient to room, put on gloves and assist with shaving/prepping/etc - Prepare materials for each case - Have gloves ready for you + fellow - Scrub whenever the fellow scrubs - Assist with draping - Assist with surgery (you will typically be 1st assist for all cases) - After case, wheel patient back to 5-N pre-op and make sure discharge orders/notes are signed - Check whiteboard to see if next patient has arrived and repeat process for next case (30 min before each case ends, you can ask the circulator to call pre-op/pre-pre-op to have the next patient brought up) 3.3.0 Orders/Notes 3.3.1 Outpatient Surgery Every patient needs the following orders signed in CPRS before they can go home: Discharge Patient - Orders(bottom tab)—>WLA_CLC_Orders_Menu(left sidebar)—>Discharge_Patient Outpatient Medications - Orders(bottom tab)—>Outpatient_Meds/Supplies(left sidebar)— >(appropriate category) Norco (10-30 tabs) +/- Keflex (3-7 days) +/- Bacitracin (apply to incision 2x per day for 1 week) +/- Kerlix/Xeroform/etc Every patient needs the following notes signed in CPRS before they can go home: PROCEDURE NOTE - Brief summary of procedure (templated) PATIENT DISCHARGE INFORMATION AND EDUCATION NOTE - Activity restrictions, dressing changes, etc (templated) 3.3.2 Inpatient Surgery Every patient needs the following orders signed in CPRS before they can be admitted: Admit Patient - Orders(bottom tab)—>Write_Delayed_Orders(left sidebar)— >PlasticsTransfer(from dropdown) (this will initiate a series of order prompts, including meds & labs) (free flap patients will go to 5th floor SICU, with q1 hour doppler checks) Every patient needs the following notes signed in CPRS before they can be admitted: S&PC BRIEF OP NOTE - Brief summary of procedure (templated) 3.4.0 General Information 3.4.1 Consents Go to Tools(top toolbar)—>iMedConsent. This will open up a separate application that walks you through the consent process. These prompts are all very generic, except for “Anatomical Location”, which is where you should specify exactly what procedure will take place (e.g., excision of right medial ankle SCC lesion with FTSG from right arm). For “Anesthesia Type”, either select General (for main OR cases) or None (for procedure room cases). Never select Moderate… this just causes problems. Consent forms can either be signed (using the signature pad) or held for signature, which allows you to save it to sign later. Consents at the VA are good for 60 days. 3.4.2 Marking Every patient has to be marked before going to the OR, even if no laterality. If no obvious markings needed, just put your initials near (but not in the way of) where they’ll be operated on. 4.0.0 Clinic 4.1.0 Times/Locations 4.1.1 WLA Clinic Wednesday Afternoon: 12:30p-5p in the 1st flr Surgery Clinic (Festekjian, Lee) Friday Morning: 8a-12p in the 1st flr Surgery Clinic (Rudkin) 4.1.2 Sepulveda Clinic Thursday Afternoon: 1p-5p at 16111 Plummer Street (3rd Flr, Plastic Surgery; Dr. Lee) (only 1st/3rd Thursdays of each month) 4.2.0 Responsibilities The fellow will give you your own room. Log onto CPRS and see patients as they come 4.2.1 See Patients - There is no great way to be alerted when a new patient arrives; just keep checking with front desk - Bring patient back to room, pull up chart in CPRS, interview, and take notes - When ready, present to fellow or attending (usually fellow first unless they’re busy) 4.2.2 Write Notes - Write notes for each patient that you see, co-signed by the appropriate attending (if fellow saw patient instead of attending, then just default to whichever attending’s clinic it is) - If patient is a new consult, make sure your note is a Plastic Surgery Resident Consult note, and tied to the correct consult request - If patient is not a new consult, then use Plastic Surgery Resident Progress Note 4.2.3 Get Consents If patient is to be scheduled for surgery, the fellow/attending will ask that you consent them using iMedConsent as described in 3.4.1 4.2.4 Procedures If patient has a procedure performed in clinic (e.g., skin tag removal), then this also needs a consent as above. Additionally, a separate Procedure Note is also needed, similar to the Brief Op notes used for OR cases. 4.2.5 RTC Orders Per national VA policy, all patients seen in clinic must now have a Return To Clinic order placed in their chart. To do this in CPRS, go to Orders—>OTHER—>”RTC All Clinics”—>WLA-Plas. Remember to sign order. After order is placed, bring patient and patient’s chart back to front desk to schedule followup if needed. 5.0.0 Rounding Rounding on this service is very informal 5.1.0 Weekdays Fellow will instruct you when to round him. Typically 15-30 min before you guys need to be in OR/clinic. Sometimes will just squeeze in during the day. No need to pre-round. Attendings will contact fellow if they want to see specific patients. 5.1.1 Primary Patients Patients on the Plastics service get rounded on and need notes every day 5.1.2 Consult Patients Consult patients that we are following will often get rounded on less frequently, but should generally be seen (and have a note written) at least once per week 5.2.0 Weekends Round on inpatients alone on days that you are on call. Txt fellow with an update and write notes. 6.0.0 New Consults 6.1.0 Inpatient Other teams will page you throughout the day to request a Plastics consult. Take down all the relevant info and ask that they submit a formal consult request through CPRS. Let fellow know, and you will probably see together later that day. When you write your note, make sure that you change the location to “WLA-PLA”!! 6.2.0 ER The ER may page you with either consults that they want your recommendations on, or more rarely with “consults” that they think need to be admitted to your service. Take down all the relevant info and ask that they submit a formal consult request through CPRS. Let fellow know, and you may be asked to run over and take a quick look before the two of you see together later in the day. When you write your note, make sure that you change the location to “WLA-PLA”!! 6.3.0 Clinic These are patients referred to our clinic from another service. The “consult” status in this case is more of a record-keeping tool to ensure that veterans have appropriate “access to care”, but it is still very important that they get appropriate Consult Notes (vs otherwise identical Clinic Notes). 7.0.0 Ob/Gyn 7.1.0 Overview The Plastics intern is responsible covering all OB/GYN inpatients and post-op patients. The Plastics fellow has no role in this, and you instead work directly with a GYN fellow. GYN only has OR on Tuesday, and most of their patients go home the same day, and you may never hear about them; others can stay for up to a week, and you will have to round on them, write notes, and handle pages. You are only responsible for both their post-op course and eventual discharge 7.2.0 Post-Op Orders Typically only applies to patients being admitted. GYN fellow should text you details. See 1.2.2 (Gyn OR) 7.3.0 Inpatients - Round on in the morning by yourself and text updates to GYN fellow. Write progress notes for each patient - Your note type will be “Gynecology Resident Progress Note”, with co-signer/attending Robin Faries-Eisner; also add the GYN fellow as a co-signer to notes - Because GYN has no admit order set, these patients get admitted through the “Admit to Plastics” set, but just make sure that “Gynecology” is listed as the Team Typical Gynecology post-op orders: POD 0 PCA 0.2 lockout 6 min dose 2.0 Zofran, Colace CLD, NS@120 until tolerating PO SCDs, IS, OOB AM CBC, BMP POD 1 d/c PCA, d/c foley, d/c IVF f/u CBC Percocet 5/325 q6h PO prn Toradol 30mg q6h IV prn POD2 Discharge orders, discharge summary Motrin 400 mg q6 prn; Percocet 5/325 q6 prn Colace; Ferrous Sulfate 325mg qd D/C Instructions: No heavy lifting; one stair at a time; nothing per vagina x 4 weeks; keep incision c/d; RTC 4 weeks; ER for severe abdominal pain, N/V, vaginal bleeding soaking 1 pad/hr 7.4.0 Signout This can be very confusing to nightfloat. The GYN Fellow is on call for all post-op patients (post-op inpatient admits or post-op patients calling from home with problems). The attending (Dr. Faries-Eisner) is on call for all new GYN consults. If it’s unclear, they can just page the fellow and he’ll direct them appropriately. 8.0.0 Writing Notes 8.1.0 Types of Notes PLASTIC SURGERY RESIDENT H&P For new patients admitted or transferred to our service PLASTIC SURGERY RESIDENT CONSULT This takes the form of a full H&P, but use for any ER/inpatient/clinic consult. When you write your note, make sure that you tag the appropriate consult request and change the location to “WLA-PLA”!! PLASTIC SURGERY RESIDENT PROGRESS This is for existing inpatients or consults. Standard SOAP note. PLASTIC SURGERY RESIDENT CLINIC NOTE Same as Progress Note, but for clinic patients (except new consults) S&PC BRIEF OP NOTE Brief summary of procedure (templated) for all OR cases. PROCEDURE Same as Brief Op Note, but for procedures done during clinic visits or Thursday procedure room cases. Need to include appropriate CPT codes under “Encounter” PATIENT DISCHARGE INFORMATION AND EDUCATION NOTE Used for patients discharged from inpatient ward and for same-day surgery patients to go home. Activity restrictions, dressing changes, etc (templated) 8.2.0 Attending Supervision The default is to list Dr. Rudkin. If another attending saw/discussed the patient instead, then use that attending. If it’s another attending’s clinic (i.e., Dr. Lee on Thursday), then list her instead. There is a difference between “Discussed with” and “Discussed with and examined with”, so select appropriately. If you took pictures of the patient and showed them to the attending during the discussion, you can use “Discussed with and examined with” 8.3.0 Cosigners Same as Attending Supervision above 8.4.0 Encounter Information 8.4.1 Visit Type (very important) - Make sure Type of Visit is correct (especially for new Consults) - Make sure Section Name is correct (use your judgment; most visits will be “Detailed” or “Comprehensive, Moderate”) - Make sure “Current providers for this encounter” includes the appropriate attending (set as primary) - Make sure any unchecked boxes (e.g., MST, agent orange, etc) are ticked, or the encounter will register as incomplete 8.4.2 Diagnosis (less important) - Choose from Problem List Items if appropriate - If not, free text search under Other Diagnosis and select the best match 8.4.3 Procedures (very important, but only applicable for clinic/procedureRoom procedures) - Select “Other Procedure” and enter the appropriate entry from the separate CPT Codes document - Make sure that the Provider tab at the bottom of the screen lists the attending (not you) 9.0.0 Signout Signout occurs in-person at 6pm in the 5S workroom. You bring your printed-out signout sheet, give it to the anesthesia intern on call, and tell them about each patient. Since this rotation is light on inpatients, you will occasionally be finished well before 6pm. You are still technically required to remain in house and sign out in person at 6pm. Anesthesia has recently been very accommodating and allowed the intern to leave a physical copy of our Plastics/Gyn list in the 5S workroom and simply call/text them for signout at 6pm (must call text if patients on our service). This is not required - they are doing us a big favor, so please be kind to them accordingly so that they continue to allow us to leave early! 10.0.0 FAQ How can I contact the VA plastics attendings? George Rudkin – p12522 Jaco Festekjian – p22080 Justine Lee – p28632 Which OR is 9 and which is 10? 9 is the more proximal one (one on the right) How do I view OR cases? CPRS—>(top)Tools—>AA/RT—>OR Schedule Viewer—(re-login)—>File—>Select Date How do I obtain remote access? See attached document How do I view active/former Consults? CPRS—>(bottom)—>Consults—>Look on left bar What are standard VA Plastics discharge instructions? No showering for 24/48/72 hours post-operatively Keep dressing in place for 3-7 days or until clinical followup (shorter for smaller surgeries) No swimming or baths involving affected area for 3-4 weeks No heavy lifting for 1-2 weeks (longer for major surgeries) No contact sports for 4-6 weeks Do not drive while on narcotic pain medication RTC in 2 weeks Standard RTC precautions (check this box on the discharge form) What are standard VA Plastics same-day surgery discharge Meds? See 3.3.1 (Outpatient Surgery) What are standard VA Plastics inpatient discharge Meds? Can vary greatly; always ask fellow How long is the wait for dialing 0 (operator)? Very long. In general, don’t bother How long is the wait for dialing the CPRS help desk? Similar to dialing 7-CARE at UCLA. Can be very useful during business hours. If I get a consult page at 5:59p, do I still have to stay and see it? How long will I have to stay? Technically yes (and in reality probably also yes). If you get a late consult you may end up staying considerably past 6pm, since the fellow will expect you to stay until it is resolved and notes have been written. What if I go over 80 hrs per week? Tell the fellow. Preferably, let them know beforehand if you are on track to break 80. In general you should be safely under the limit on this rotation How do I view more/earlier notes in CPRS? Go to View->CustomView—>”Max Number To Return” How long is a VA consent good for? 60 days Pager numbers or extensions in the signout sheet appear incorrect? Some of this info appears to be outdated. Please update it if you find an error